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San Joaquin County <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue, Stockton, CA 95205 <br /> (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br /> Public Works Waste Pickup and Transportation <br /> i. Date: —1-7-177 z CO (0)(0) q <br /> 3. Time: I 100 4. EPA ID #: CAS111111039 <br /> s. Transporter Registration #: 6148 <br /> 6. Reporting Party: OPW SO E]CHP Others: �( <br /> 7. Waste Pick-up Address: 0, <br /> a. Destination: 7850 S R A Bridgeford, St kton, CA 95206 <br /> 9. Containers io. Waste <br /> # Quantity Size Description <br /> 1 2 3O Lb R -2Z r� rig �►-►f <br /> 2 1 5 fall on M'I_I_ <br /> 3 <br /> 4 <br /> 5 <br /> ii. Emergency Contact <br /> Environmental Health Department: (209) 468-3420 <br /> 12. Special Instructions and Other Comments <br /> 13.Signature: <br /> i4. Inspector Name: is.Title: ` , <br />